BILIRUBIN

METABOLISM
AND
JAUNDICE
M IN DA N A O
D R . J O H N PA U L G . M A L E N A B
S TAT E U N I V E R S I T Y C O L L E G E O F M E D I C I N E
BILE SECRETION BY THE LIVER
– Bile secretion 600 – 1000 mL/day
– Functions:
1. Role in fat digestion and absorption
a. Bile acids
- Emulsify large fat particles of the food into many minute particles
- Aid in absorption of digested fat end products
2. Means for excretion of secretion of waste (Bilirubin, Excess cholesterol)
 LIVER
SECRETION
AND
GALL
BLADDER
EMPTYING
STORING AND CONCENTRATING BILE

• Bile secreted by liver cells continuously

• Stored in bile
• Max Volume that GB can hold: 30 to 60 mL
– 12 hours of bile secretion = 450 mL can be stored
– Water, sodium, chloride = continuously absorbed through the GB mucosa
– Concentrated Bile remains
• Contains bile salts, cholesterol, lecithin and bilirubin
COMPOSITION OF BILE
CHOLECYSTOKININ
FUNCTION OF BILE SALTS IN FAT
DIGESTION AND ABSORPTION
• Liver cells – synthesize 6 gm of bile salts per day
• CHOLESTEROL – precursor of bile salts
– Cholic and chenodeoxycholic acid
– Combine with glycine and taurine
• Intestinal tract
– Detergent actions in the intestinal tract
– Absorption of fatty acids, monoglycerides, cholesterol and other lipids
• Formation of micelles
• 40% ingested fat are lost without bile salts
BILIRUBIN
METABOLISM
• Bilirubin
– Tetrapyrrole pigment
– Breakdown product of heme (ferroprotoporphyrin
IX)
– 250-300 mg of bilirubin produced each day
• Derived from hemoglobin breakdown in
senescent red blood cells = 70-90%
• Prematurely destroyed erythroid cells in
bone marrow
• Turnover of hemoproteins such as myoglobin
and cytochromes found in tissues in the
body
– Formation occurs in the Reticuloendothelial
cells
• Spleen and Liver
BILIRUBIN
METABOLISM
• FIRST REACTION
– HEME OXYGENASE (microsomal
enzyme)
• Oxidatively cleaves the alpha bridge
of the porphyrin group and opens
the heme ring.
• END products
– Biliverdin
– Carbon monoxide
– Iron (Fe)
 BILIRUBIN
METABOLISM
• SECOND REACTION
– BILIVERDIN REDUCTASE (cytosolic enzyme)
• Reduces the central methylene bridge of
biliverdin and converts it to BILIRUBIN
• Bilirubin formed in the RES
– Virtually insoluble in water
– BOND between the Propionic acid
carboxyl groups of one dipyrrolic half of
the molecule with the imino and lactam
groups of the opposite half
– Blocks solvent access to the polar
residues of bilirubin = hydrophobic
residues on the outside
BILIRUBIN
METABOLISM
• SOLUBILIZATION
– Important in transporting bilirubin to blood
– Accomplished by reversible, non-covalent
binding of bilirubin to albumin
– Unconjugated bilirubin bound to albumin
=> transported to the Liver
– Bilirubin – taken up by hepatocytes via a
process
• Unidentified carrier-mediated
membrane transport
 BILIRUBIN METABOLISM
• In the LIVER
– Unconjugated Bilirubin – bound in cytosol to a
number of proteins
• Glutathione-S-transferase superfamily
– Reduce efflux of bilirubin back to the serum
– Present bilirubin for conjugation
• In the Endoplasmic reticulum
– Bilirubin is solubilized by conjugation to Glucoronic acid
– Disrupts internal hydrogen bonds = yields bilirubin
monoglucuronide and diglucuronide
– Catalyzed by the enzyme Bilirubin Uridine Diphosphate-
Glucuronyl transferase (UDPGT).
– Diffuse from ER to Canalicular membrane =>
transported to canalicular bile
• Energy-dependent mechanism = Multidrug
resistance-associated protein 2 (MRP2)
BILIRUBIN METABOLISM
• In the Duodenum
– Conjugated Bilirubin excreted into the bile
• Drains into the duodenum (unchanged
through the proximal small bowel)
• Distal ileum and colon => hydrolyzed to
Unconjugated bilirubin by Bacterial Beta
glucoronidases
• Unconjugated bilirubin is reduced by normal
gut bacteria to form a group of colorless
tetrapyrroles called UROBILINOGENS
– 80-90% excreted in FECES or oxidized to
orange derivatives called UROBILINS
– 10-20% => passively reabsorbed and
enter the portal venous blood or re-
excreted by the liver
– <3 mg/dL excapes hepatic uptake =>
filters across the renal glomerulus =>
excreted in Urine
 BILIRUBIN METABOLISM
RES Blood Liver GUT Excretion/
Reabsorption

Unconjugated
bilirubin Albumin Uridine diphosphate Gut bacteria FECES
Glucoronyl (Stercobilin)
Transferase 80-90%

Unconjugated
bilirubin-albumin URINE
complex (Urobilins)
(Indirect bilirubin) Conjugated Urobilinogen 2%
Heme Bilirubin
(Direct Bilirubin)

Enterohepatic
Macrophage CIRCULATION
10-20%

RBCs
MEASUREMENT OF SERUM BILIRUBIN
• Direct or Conjugated Bilirubin
• Indirect or Unconjugated Bilirubin
• Assay = van den Bergh reaction
– Bilirubin => exposed to diazotized sulfanilic acid
– Split into two stable dipyrrlmethene azopigments (analyzed photometrically at 540
nm)
• Direct fraction = approximates Conjugated Bilirubin
– 30% or 5.1 umol/L (0.3 mg/dL)
• Total Bilirubin = amount that reacts after addition of ALCOHOL
– 17 umol/L (<1 mg/dL)

• Indirect Fraction = difference between the two values

MESUREMENT OF URINE BILIRUBIN

• Unconjugated bilirubin is always bound in the serum

– Not filtered by the kidneys
– Not found in the urine
• Conjugated Bilirubin is filtered in the glomerulus
– Majority reabsorbed = proximal tubules
– Small fraction excreted in the urine
– Bilirubinuria = > implies Liver disease
• FALSE NEGATIVE TEST
– Prolonged cholestasis due to predominance of delta bilirubin (covalently bound to albumin)
JAUNDICE

• Jaundice
– Aka Icterus
– Yellow discoloration of tissue
resulting from deposition of bilirubin
– Presence of serum hyperbilirubinemia
– Liver disease or hemolytic disorder
(less likely)
– Scleral icterus = bilirubin level
51 umol/L (3 mg/dL)
JAUNDICE
• Carotenoderma
– Excessive amounts of fruits/vegetables with carotene
– Pigment concentrated on palms, soles, forehead,
nasolabial folds
– Scleral sparing
• Quinacrine Use
– 4-37% of treated patients
• Excessive Exposure to phenols
• Darkening of urine (Tea-colored urine)
– Renal excretion of Conjugated Bilirubin
ISOLATED ELEVATION
OF SERUM BILIRUBIN

• Determine:
– Hemolytic process
• Hemolytic disorders
• Ineffective erythropoiesis
– Impaired Hepatic uptake/conjugation
of bilirubin
• Drug effect
• Genetic disorders
ISOLATED ELEVATION
OF SERUM BILIRUBIN

Hemolytic disorders:
• the serum bilirubin level rarely exceeds 86 μmol/L
(5 mg/dL).
- Higher levels = coexistent renal or
hepatocellular dysfunction or in acute
hemolysis, such as a sickle cell crisis.
- Patients with chronic hemolysis: remember the high
incidence of pigmented (calcium bilirubinate)
gallstones
- increases the likelihood of choledocholithiasis
as an alternative explanation for
hyperbilirubinemia.
ISOLATED ELEVATION
OF SERUM BILIRUBIN
- Resorption of Hematomas/ Massive Blood
transfusions
- Increase Hemoglobin release and Overproduction of
bilirubin
- Rifampicin and Probenecid
- Unconjugated hyperbilirubinemia = diminished
hepatic uptake of bilirubin
 ISOLATED ELEVATION
OF SERUM BILIRUBIN
- Impaired bilirubin conjugation
- Crigler-Najjar Type 1 (rare): Severe jaundice
- Levels >342 umol/L (>20 mg/dL
- Neurologic impairment (Kernicterus)
- Complete absence of bilirubin UDPGT activity (critical 3’ domain mutation)
- High Mortality
- Crigler-Najjar type II (more common than Type I)
- Live into adulthood
- Levels 103-428 umol/L (6 -25mg/dL
- Mutated bilirubin UDGPT but not complete eradication of enzyme activity
- Bilirubin UDGPT activity can be induced by administration of phenobarbital
(decreasing bilirubin levels)
- Kernicterus = stress from intercurrent illness or surgery
- Gilbert’s Syndrome (Very common)
- 3-7% of population
- M>F 2-7:1
- Impaired Conjugation – approx. 1/3 of normal
- Reduced transcription of bilirubin UDGPT
- Level <103 umol/L (6 mg/dL)
- Fluctuate = jaundice ID during FASTING
ISOLATED ELEVATION
OF SERUM BILIRUBIN
Conjugated Hyperbilirubinemia
- Both present with asymptomatic jaundice
• Dubin-Johnson Syndrome
– Gene mutation for MRP2
– Altered excretion of bilirubin into bile ducts
• Rotor Sydrome
– Deficiency of major hepatic drug uptake
transporters OATP1B1 and OATP1B3
HYPERBILIRUBINEMIA + OTHER LIVER
TEST ABNORMALITIES
History
- Single most important part of evaluation
- Exposure to chemical/medication/CAM
- Parenteral exposures
- Sexual Activity
- Recent travel history
- Exposure to people with jaundice
- Presence of accompanying Signs/Symptoms
Physical examination
- Nutritional status
- Temporal and proximal muscle wasting
- Stigmata of chronic liver disease
- Spider nevi; palmar erythema; gynecomastia; caput
medusae; dupuytren’s contractures; parotid
enlargement; testicular atrophy
- Virchow’s or Sister Mary Joseph’s nodule
- Jugular venous distention
- Right sided pleural effusion
- Size of Liver and Spleen
- Tender Liver
- RUQ tenderness
- Ascites + Jaundice
HEPATOCELLULAR CONDITIONS

• Wilsons = primarily in young adults

• Autoimmune hepatitis = young middle aged women
– (but may affect Men or women of any age).
- Alcoholic hepatitis = differentiated from viral and toxin-related hepatitis by pattern of
aminotransferases
- Alcoholic hepatitis = AST to ALT ratio of at least 2:1, AST levels rarely >300 U/L
- Acute Viral Hep and Toxin related injury = >500 U/L; ALT >/= AST.
- ALT and AST values <8 X normal may be seen in either hepatocellular or cholestatic disease
- Values 25 times normal or higher are seen primarily in acute hepatocellular diseases.
HEPATOCELLULAR CONDITIONS

- Jaundice from cirrhosis = Normal or slightly elevated aminotransferase levels.

- Acute: Anti HAV IgM, HBsAG, Anti HBc IgM; HCV RNA (Anti HCV takes a few weeks to
become detectable- hence unreliable for acute HCV), Hepatitis E IgM Antibody assay;
- Hep D, E, EBV, CMV may be indicated
- Ceruloplasmin = Wilson’s disease
- ANA and measurement of specific immunoglobulins = Autoimmune Hepatitis
CHOLESTATIC CONDITIONS

- Determine whether intrahepatic or extrahepatic

- Difficult to distinguish by Hx, PE, Laboratory tests
- NEXT Appropriate test is ULTRASOUND = inexpensive, no radiation
- Detects biliary dilatation with high degree of sensitivity and specificity
- Absence = intrahepatic cholestasis
- Presence = extrahepatic cholestasis
- False Negative – Partial obstruction of CBD or cirrhosis or PSC
- Scarring prevents intrahepatic ducts from dilating
- Distal CBD = difficult to visualize because of overlying bowel gas
CHOLESTATIC CONDITIONS

- NEXT: CT, MRCP, ERCP, EUS

- CT and MRCP = better than US for assessing head of pancreas and ID Choledocholithiasis in
distal CBD particularly when the ducts are not dilated.
- ERCP Gold standard for ID CHoledocholithiasis., and allows Tx Interventions
- MRCP replaced ERCP when need for intervention is thought to be small
- EUS Sn/Sp comparable to MRCP in detection of bile duct obstruction; Allows Biopsy of
suspected malignant lesions (invasive and requires sedation).
IMAGING STUDIES TO EVALUATE JAUNDICE
CHOLESTATIC CONDITIONS

• INTRAHEPATIC CHOLESTASIS
– Serologic testing + Liver biopsy
– HBV and HCV can cause cholestatic hepatitis (Fibrosing Cholestatic Hepatitis)
• Patients who have undergone solid organ transplantation.
– HAV, HEV, Alcoholic hepatitis, EBV, CMV
CHOLESTATIC CONDITIONS

• DRUGS
– Usually reversible after discontinuation of offending agent
– Most common = anabolic and contraceptive steroids
– Cholestatic Hepatitis
• Chlorpromazine, Imipramine, Tolbutamide, Sulindac, Cimetidine, Erythromycin, Trimethoprim,
sulfamethoxazole, Ampicillin, Dicloxacillin, Clavulanic Acid
– Chronic Cholestasis
• Rare
• Associated with progressive fibrosis despite discontinuation
• Chlorpromazine and Prochlorperazine
CHOLESTATIC CONDITIONS

• PRIMARY BILIARY CIRRHOSIS (PBC)

– Autoimmune disease
– Predominantly middle-aged women
– Destruction of interlobular bile ducts
– Dx: detection of Antimitochondrial Antibody (AMA).
• PRIMARY SCLEROSING CHOLANGITIS (PSC)
– Destruction and fibrosis of larger bile ducts
– Dx: CHOLANGIOGRAPY (ERCP or MRCP)
• Pathognomonic segmental strictures.
– 75% of Pxs with PSC have Inflammatory bowel disease (IBD)
CHOLESTATIC CONDITIONS

• VANISHING BILE DUCT SYNDROME (VBDS) and ADULT BILE DUCTOPENIA

– Rare
– Decreased number of bile ducts seen on liver biopsy
– Histologic picture similar to PBC
– Seen in patients who develop chronic rejection after Liver Transplantation(LT) or Graft-versus-host
disease (GVHD) after bone marrow transplantation.
– VBDS = also occur in Sarcoidosis; Chlorpromazine and idiopathically.
CHOLESTATIC CONDITIONS
• Familial Forms
– Progressive Familial Intrahepatic Cholestasis (PFIC) tupes 1 to 3
• Progressive – occurs in childhood
• PFIC2 = ABCB11 mutation = bile salt export pump
• PFIC3 multidrug resistant P-glycoprotein mutation
– Benign recurrent cholestasis (BRC)
• Presents later in life
• Recurrent episodes of jaundice and pruritus
• Self-limited but debilitating
– Both are autosomal recessive disease with mutations in ATP8B1
• Encoded protein from subfamily of P-type ATPase
• CHOLESTASIS OF PREGNANCY
– 2nd and 3 rd trinmester = resolves after delivery
– Unknown cause
– Probably inherited?
– Can be Triggered by estrogen administration
CHOLESTATIC CONDITIONS

• OTHERS
– TPN
– Non-hepatobiliary sepsis
– Benign postoperative cholestasis
– Paraneoplastic syndrome
• Associated with Hodgkin’s disease, medullary tyroid cancer, renal cancer, renal cell cancer, renal sarcoma, t-cell
lymphoma, protate cancer
– Ischemic hepatitis = acute hypoperfusion = acute/dramatic elevation of aminotransferases followed by
gradual peak in serum bilirubin
– Veno-occlusive disease – jaundice occurring after bone marrow transplantation
– Heart failure Jaundice – late finding due to hepatic congestion and hepatocellular hypoxia
CHOLESTATIC CONDITIONS

• INFECTION
– Malaria = indirect hyperbilirubinemia (hemolysis)
• Cholestatic and hepatocellular jaundice
– Weil’s disease – severe Leptospirosis
• Jaundice and renal failure, fever, headache and muscle pain
CHOLESTATIC CONDITIONS
• EXTRAHEPATIC CHOLESTASIS

MALIGNANT BENIGN
• Pancreatic • Choledocholithiasis – most common
• Gall Bladder extrahepatic cholestasis
• Ampullary • PSC with extrahepatic stricture
• Cholangiocarcinoma – associated with • IgG4-associated cholangitis – marked
PSC structuring of biliary tree = responsive
• Hilar Lymph Node Metastasis to glucocorticoid therapy
• Structures due to Chronic pancreatitis
• AIDS Cholangiopathy (infection with
CMV or Cryptosporidia)
• Infections (most common in
developing countries).